Frailty is defined as a state of decline and susceptibility in which the older adult is unable to return to a homeostatic state after the presence of a stressor. Frailty is associated with an increased risk of physical dependency and/or mortality.
Objectives 1. Define frailty and discuss the two prominent models behind frailty. 2. Discuss the prevalence of frailty. 3. Identify those who need to be screened for frailty. 4. Identify valid and reliable measures of frailty. 5. Discuss evidence-based interventions to treat frailty.
Pathophysiology of Frailty
Ageing is thought to be the consequence of the collection of molecular and cellular damage caused by mechanisms of body maintenance and repair. This collection of waste has a detrimental effect on the systems in our body. Waste products can affect the endocrine, immune, musculoskeletal, cardiovascular, respiratory, central nervous system and renal system. The CNS, endocrine system, immune system and musculoskeletal system are the most researched in the development of frailty. Consequences of aging along with, environmental and lifestyle factors influence the development of frailty in the older adult. Frailty increases the risk of unwanted results including falls, delirium and disability. These unwanted outcomes are common reasons for hospital and long term care admissions.
Two Main Models
Frailty Index Model
The Frailty Index (FI) was developed in the second stage of the Canadian Study of Health and Aging (CSHA). The CSHA was a five-year prospective cohort study of over 10,000 individuals aged 65 and older. The Frailty Index is a count of 70 clinical deficits from the previous CSHA assessment. Categories included in the FI are presence and severity of current diseases, ability to complete ADLs, along with physical and neurological signs. The index is a simple calculation of the presence or absence of the 70 variables. Therefore, frailty is defined as the accumulation of deficits in the older adult that contributes to an increased risk of mortality. This is consistent with the increased susceptibiliy and threat of homeostatic collapse that is fundamental to the frailty definition.
Physical Phenotype Model
Frailty indictor
Measure
Weight loss
Self-reported weight loss of more than 10 pounds or recorded weight loss of ≥ 5% per annum
Self-reported exhaustion
Self-reported exhaustion on CES-D depression score (3-4 days per week or most of the time)
Low energy expenditure
Energy expenditure <383 KCal/week (males) or <270 KCal/week (females)
Slow gait speed
Standardized cut-off times to walk 15 feet, stratified for sex and height
Weak grip strength
Grip strength, stratified by sex and BMI
In a study by Fried et al, a secondary analysis of data from a prospective cohort study (the Cardiovascular Health Study (CHS)) was conducted to define a frailty phenotype. The study included 5,210 men and women aged 65 and older. The phenotype consists of a cluster of variables presented in the table above. Participants with Pakinson’s disease, previous stroke, cognitive impairment and/or depression were excluded in the study. Individuals with 3 out of the 5 factors are considered to be frail, one to two factors are considered pre-frail, and no factors are considered healthy older adults.
Prevalence 4 to 17% of persons aged 65 and older are considered frail Women are 2x as likely as men to be frail Prevalence increases in individuals > 80 years old
Individuals At risk of Developing Frailty
Heart failure
Cancer
Renal Failure
HIV
Diabetes
Undergoing surgery
Who should be screened? Individuals age 70 and over People experiencing significant weight loss (>5 % over the past year) due to chronic illness
Assessment Tools FRAIL Gait Speed Tillburg Frailty Indicator The Edmonton Frail Scale Cardiovascular Health Study Frailty Screening Measure Clinical Frailty Scale Gérontopôle Frailty Screening Tool
Treatment Nutrition and supplementation (Calorie and protein support, Vitamin D) Balance training Gait Training
Aerobic Training
Resistance Training Try to reduce polypharmacy
Author
Treatment
Results
Singh et al
1 year resistance exercise following hip fracture
Decreased hospitalization, nursing home placement
Yamanda et al
Community based exercise program
Effective in preventing frailty progression and disability
Theou et. al
45-60 minutes of exercise 3x/wk
Management of frailty
Gillespie et al
Exercise
Increases functional performance, walking speed, chair stand, stair climbing, balance, decreased depression, decreased fear of falling
Paddon-Jones et al, Malafarina et al, Tieland et al, Morley et al, Cawood et al
Protein Supplement
Produces weight gain, increases muscle mass, improves strength, reduces complications, act together with resistance exercise
Kojima et al, Fitzgerald et al, Tamura et al, Morley et al, Merle et al
Reduce polypharmacy
Decrease costs, medication side effects
References:
1. Morley J, Vellas B, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013;14 (6): 392-397. 2. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community- dwelling older persons: A systematic review. J Am Geriatr Soc. 2012; 60:1487–1492. 3. Lancet. Frailty in Older People. Europe PMC Funders. 2013; 381(9868): 752–762. 4. Rockwood K, Song X, et al. A global clinical measure of fitness and frailty in elderly people. JAMC. 2005:173: 489-495. 5. Afilalo J. Frailty in patients with cardiovascular disease: Why, when and how to measure. Curr Cardiovasc Risk Rep. 2011; 5:467–472. 6. Ruiz M, Reske T, Cefalu C, Estrada J. Management of elderly and frail elderly patients: The importance of comprehensive geriatrics assessment and the need for guidelines. Am J Med Sci. 2012 Nov 17. Epub ahead of print. 7. Shilpak MG, Stehman-Breen C, Fried LF, et al. The presence of frailty in elderly persons with chronic renal insufficiency. Am J Kidney Dis. 2004; 43:861–867. 8. Desquilbet L, Jacobson LP, Fried LP, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007; 62:1279–1286. 9. Sinclair A, Morley JE, Rodriguez-Mañas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc. 2012; 13:497–502. 10.Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: A review. Age Ageing. 2012; 41:142–147. 11.Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc. 2012; 13:24–30. 12.Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc. 2012; 13:507– 511. 13.Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: A systematic review. J Aging Res. 2011. 14.Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012; 9. 15.Paddon-Jones D. Perspective: Exercise and protein supplementation in frail elders. J Am Med Dir Assoc. 2013; 14:73–74. 16.Malafarina V, Uriz-Otano F, Iniesta R, Gil-Guerrero L. Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: A systematic review. J Am Med Dir Assoc. 2013; 14:10–17. 17.Tieland M, Dirks ML, van der Zwaluw N, et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc. 2012; 13:713–719. 18.Morley JE. Do frail older persons need more protein? J Am Med Dir Assoc. 2012; 13:667–668. 19.Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012; 11:278–296. 20.Kojima G, Bell C, Tamura B, et al. Reducing cost by reducing polypharmacy: The polypharmacy outcomes project. J Am Med Dir Assoc. 2012; 13:811–818. 21.Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatments—implications for guidelines and polypharmacy. J Am Med Dir Assoc. 2010; 11:475– 484. 22.Tamura BK, Bell CL, Lubimir K, et al. Physician intervention for medication reduction in a nursing home: The polypharmacy outcomes project. J Am Med Dir Assoc. 2011; 12:326–330. 23.Morley JE. Polypharmacy in the nursing home. J Am Med Dir Assoc. 2009; 10:289–291. 24. Fried LP, Tangen CM, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56 (3): 146-156. 25. Merle L, Laroche ML, Dantoine T, Charmes JP. Predicting and preventing adverse drug reactions in the very old. Drugs Aging. 2006; 22:375–392.
Frailty is defined as a state of decline and susceptibility in which the older adult is unable to return to a homeostatic state after the presence of a stressor. Frailty is associated with an increased risk of physical dependency and/or mortality.
Objectives
1. Define frailty and discuss the two prominent models behind frailty.
2. Discuss the prevalence of frailty.
3. Identify those who need to be screened for frailty.
4. Identify valid and reliable measures of frailty.
5. Discuss evidence-based interventions to treat frailty.
Pathophysiology of Frailty
Ageing is thought to be the consequence of the collection of molecular and cellular damage caused by mechanisms of body maintenance and repair. This collection of waste has a detrimental effect on the systems in our body. Waste products can affect the endocrine, immune, musculoskeletal, cardiovascular, respiratory, central nervous system and renal system. The CNS, endocrine system, immune system and musculoskeletal system are the most researched in the development of frailty. Consequences of aging along with, environmental and lifestyle factors influence the development of frailty in the older adult. Frailty increases the risk of unwanted results including falls, delirium and disability. These unwanted outcomes are common reasons for hospital and long term care admissions.
Two Main Models
Frailty Index Model
The Frailty Index (FI) was developed in the second stage of the Canadian Study of Health and Aging (CSHA). The CSHA was a five-year prospective cohort study of over 10,000 individuals aged 65 and older. The Frailty Index is a count of 70 clinical deficits from the previous CSHA assessment. Categories included in the FI are presence and severity of current diseases, ability to complete ADLs, along with physical and neurological signs. The index is a simple calculation of the presence or absence of the 70 variables. Therefore, frailty is defined as the accumulation of deficits in the older adult that contributes to an increased risk of mortality. This is consistent with the increased susceptibiliy and threat of homeostatic collapse that is fundamental to the frailty definition.
Physical Phenotype Model
Prevalence
4 to 17% of persons aged 65 and older are considered frail
Women are 2x as likely as men to be frail
Prevalence increases in individuals > 80 years old
Individuals At risk of Developing Frailty
Who should be screened?
Individuals age 70 and over
People experiencing significant weight loss (>5 % over the past year) due to chronic illness
Assessment Tools
FRAIL
Gait Speed
Tillburg Frailty Indicator
The Edmonton Frail Scale
Cardiovascular Health Study Frailty Screening Measure
Clinical Frailty Scale
Gérontopôle Frailty Screening Tool
Treatment
Nutrition and supplementation (Calorie and protein support, Vitamin D)
Balance training
Gait Training
Aerobic Training
Resistance Training
Try to reduce polypharmacy
References:
1. Morley J, Vellas B, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc. 2013;14 (6): 392-397.
2. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community- dwelling older persons: A systematic review. J Am Geriatr Soc. 2012; 60:1487–1492.
3. Lancet. Frailty in Older People. Europe PMC Funders. 2013; 381(9868): 752–762.
4. Rockwood K, Song X, et al. A global clinical measure of fitness and frailty in elderly people. JAMC. 2005:173: 489-495.
5. Afilalo J. Frailty in patients with cardiovascular disease: Why, when and how to measure. Curr Cardiovasc Risk Rep. 2011; 5:467–472.
6. Ruiz M, Reske T, Cefalu C, Estrada J. Management of elderly and frail elderly patients: The importance of comprehensive geriatrics assessment and the need for guidelines. Am J Med Sci. 2012 Nov 17. Epub ahead of print.
7. Shilpak MG, Stehman-Breen C, Fried LF, et al. The presence of frailty in elderly persons with chronic renal insufficiency. Am J Kidney Dis. 2004; 43:861–867.
8. Desquilbet L, Jacobson LP, Fried LP, et al. HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty. J Gerontol A Biol Sci Med Sci. 2007; 62:1279–1286.
9. Sinclair A, Morley JE, Rodriguez-Mañas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc. 2012; 13:497–502.
10.Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: A review. Age Ageing. 2012; 41:142–147.
11.Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc. 2012; 13:24–30.
12.Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc. 2012; 13:507– 511.
13.Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: A systematic review. J Aging Res. 2011.
14.Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012; 9.
15.Paddon-Jones D. Perspective: Exercise and protein supplementation in frail elders. J Am Med Dir Assoc. 2013; 14:73–74.
16.Malafarina V, Uriz-Otano F, Iniesta R, Gil-Guerrero L. Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: A systematic review. J Am Med Dir Assoc. 2013; 14:10–17.
17.Tieland M, Dirks ML, van der Zwaluw N, et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc. 2012; 13:713–719.
18.Morley JE. Do frail older persons need more protein? J Am Med Dir Assoc. 2012; 13:667–668.
19.Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012; 11:278–296.
20.Kojima G, Bell C, Tamura B, et al. Reducing cost by reducing polypharmacy: The polypharmacy outcomes project. J Am Med Dir Assoc. 2012; 13:811–818.
21.Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatments—implications for guidelines and polypharmacy. J Am Med Dir Assoc. 2010; 11:475– 484.
22.Tamura BK, Bell CL, Lubimir K, et al. Physician intervention for medication reduction in a nursing home: The polypharmacy outcomes project. J Am Med Dir Assoc. 2011; 12:326–330.
23.Morley JE. Polypharmacy in the nursing home. J Am Med Dir Assoc. 2009; 10:289–291.
24. Fried LP, Tangen CM, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56 (3): 146-156.
25. Merle L, Laroche ML, Dantoine T, Charmes JP. Predicting and preventing adverse drug reactions in the very old. Drugs Aging. 2006; 22:375–392.